Current approach in the diagnosis and management of panuveitis

Abstract

Panuveitis is a generalized inflammation of not only the whole of the uveal tract but also involves the retina and vitreous humor. It differs from other anatomical sites of inflammation in terms of causes as well as distribution. The common causes of panuveitis in our population are tuberculosis, Vogt-Koyanagi-Harada syndrome, sympathetic ophthalmia, Behcet's disease and sarcoidosis. A large number of cases still remain idiopathic. A stepwise approach is essential while evaluating these patients to be able to identify and treat the disease timely and correctly. Ancillary tests can be appropriately applied once the anatomic site of inflammation is identified. An exhaustive approach comprising a full battery of tests is obsolete. Only specific tailored investigations are ordered as suggested by the preliminary clinical and ocular examination. The mainstay of the treatment of uveitis is corticosteroids. Immunosuppressive agents are administered if the inflammation is not adequately controlled with corticosteroids. One of the recent breakthroughs in the treatment of refractory uveitis includes the introduction of immunomodulating drugs: Tumor necrosis factor-alpha antagonist and Interferon-alpha. Vitrectomy has been used in uveitis for over a few decades for diagnostic and therapeutic purposes. When compared to other anatomical sites of inflammation, panuveitis has poor visual outcome due to more widespread inflammation. The side-effects of the chronic treatment that these patients receive cannot be overlooked and should be specifically monitored under the supervision of an internist with special interest in inflammatory diseases.

Figure 1

A 14-year-old girl having bilateral granulomatous panuveitis (left top and bottom showing the right eye, and right top and bottom showing the left eye)

Figure 2

Ultrasound B-scan showed bilateral retinochoroidal thickening (arrows). Diagnosed as probable Vogt-Koyanagi-Harada's syndrome, she was treated with intensive topical betamethasone and mydriatics drops. She also received intravenous methyl prednisolone 1 g for five days followed by oral steroids

Figure 3

Anterior segment photographs of the right eye (on left) and left eye (on right) after three months of treatment; on maintenance dose of oral steroids 5 mg daily

Figure 4

At three months, both eyes showing quiescent and sunset glow fundus